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choices in childbirth

so this is like a thursday post on friday.....

this topic has been on my mind lately. and this video from msnbc brought it to the forefront for a blog post. i actually haven't watched the video b/c i don't have speakers on my computer right now but i did post a reply on the discussion (the question was basically what are your thought on the risks of homebirth) heres my reply

"Its always a risk/benefit analysis. There are risks and benefits to either scenerio and its a matter of choosing which risks are acceptable and which benefits are most important to you.

there are benfits to homebirth that show up in the research: fewer interventions, more skin-to-lskin, more rapid initiation of breastfeeding, greater satisfaction with the birth experience, one-to-one care for mom, etc

there are also risks. an emergent situation can arise that requires urgent action. sometimes a transfer to hospital care can be accomplished in time and sometimes time is of such essence that a transfer can't be accomplished in time. sometimes a woman will find labor to be more painful or more exhausting than anticipated and she wil want to tranfer for a non-emergent complication.

there are several kinds of midwives and the kind of training they have will vary but most midwives have training in ergency situations. most midwives can perform at least basic rescucitation on mom and or baby. many midwives carry oxygen, pitocin, suture equipment and other equipment to deal with emergencies. that would definately be a question to ask a midwife: "what kind of training do you have to manage an emergency?" "what are your transfer protocols?" etc

there are times when the benefits of a hospital birth will outweigh the benefits of a homebirth. if a woman goes into pre-term labor at say 32 weeks, or has pre-eclamsia, or an unmanaged health condition then a hospital birth may be the wisest choice. but there are very real rsks to hospital birth. some of these risks are the same risks anyone faces walking into a hospital : hospital aquired infection, medication errors, miscommunications between care providers during shift changes. some risks are specific to labor and delivery. the epidural delivers very good pain relief but it can also cause fever and a decrease in blood pressure. pitocin can jump start contractions but those contractions can be very intense and can even hyperstimulate the uterus leading to an emergency section. even some basic hospital procedures such as denying food and drink carry risks. you wouldn't run a marathon w/o adequate nourishment why expect to have a baby w/o eating and drinking?

the way transfers are managed is one area where improvement is sorely needed. a study was done recently that showed that there is so much fear on both sides that it is affecting the care women recieve when a transfer is needed. i think some kind of no-fault transfer policy needs to be implemented at a national level so obs can use their training when it is needed w/o fear of a lawsuit, so midwives can transfer women who need hospital services w/o fear of everyone can share information freely and no one lets fear get in the way of care.

and as to the actual question, i've had 2 hospital births and one birth in a freestanding birth center. if i have another it will be a planned homebirth."

And this topic homebirth versus hospital gets to the heart of the matter. Your choices in childbirth boil down really to 2 things: your choice of healthcare provider and your choice of birthing place.

Many many women plan to just use whoever they've been using for well woman gyno care. You probably know and like your hcp. But this post from jen at vbac facts demonstrates how liking your hcp is not enough.

you pretty much have 3 choices in birth care: An OB, a family practice dr, or a midwife. any one of the 3 can be a good choice if they have a birth philosophy that works for you but in general obs will be the most interventive of the 3 and midwives the least interventive.

midwives work within the midwifery model of care.

The Midwives Model of Care

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:

  • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
  • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
  • Minimizing technological interventions
  • Identifying and referring women who require obstetrical attention

The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights Reserved

An OB on the other hand is a sugeon trained in the technocratic model of care. this is a long read but explains the technocratic model in great detail

basically in the technocratic model the birthing mother is seen as a machine destined to malfunction at some point.

Afamily practice dr who still attends births is hard to find but if found is oftn somewhere in between midwife and ob in mindset.

regardless of the letters behing your hcp's name you have got to be sure your birth philosophy meshes with theirs. Because if she usually cuts an episiotomy she'll probably cut one on you too. If he only "allows" a 12 hour labor before he starts a pit drip to "move it along" thats probably the care you'll get too.

And then you also have to be sure that the place you choose to give birth is willing and able to be supportive of your birth philosophy also. What are their usual procedures? If everybody who goes to hospital A has to do some time on the fetal monitor you probably will too unless your dr or midwife has okay'd you not doing it in advance. if they don't "allow" most of their mothers to labor in the tub they probably won't "let" you either.

a good place to start is with this list from the coalition for improving maternity services

Having a Baby?
Ten Questions to Ask
©2000 Coalition for Improving Maternity Services (CIMS).

1. Ask, “Who can be with me during labor and birth?”
Mother-friendly birth centers, hospitals, and home birth services will let a birthing mother decide whom she wants to have with her during the birth. This includes fathers, partners, children, other family members, or friends.
They will also let a birthing mother have with her a person who has special training in helping women cope with labor and birth. This person is called a doula or labor support person. She never leaves the birthing mother alone. She encourages her, comforts her, and helps her understand what’s happening to her.
They will have midwives as part of their staff so that a birthing mother can have a midwife with her if she wants to.
2. Ask, “What happens during a normal labor and birth in your setting?”
If they give mother-friendly care, they will tell you how they handle every part of the birthing process. For example, how often do they give the mother a drug to speed up the birth? Or do they let labor and birth usually happen on its own timing?
They will also tell you how often they do certain procedures. For example, they will have a record of the percentage of C-sections (Cesarean births) they do every year. If the number is too high, you’ll want to consider having your baby in another place or with another doctor or midwife.
Here are some numbers we recommend you ask about.
They should not use oxytocin (a drug) to start labor for more than 1 in 10 women (10%).
They should not do an episiotomy (ee-pee-zee-AH-tummy) on more than 1 in 5 women (20%). They should be trying to bring that number down. (An episiotomy is a cut in the opening to the vagina to make it larger for birth. It is not necessary most of the time.)
They should not do C-sections on more than 1 in 10 women (10%) if it’s a community hospital. The rate should be 15% or less in hospitals which care for many high-risk mothers and babies.
A C-section is a major operation in which a doctor cuts through the mother’s stomach into her womb and removes the baby through the opening. Mothers who have had a C-section can often have future babies normally. Look for a birth place in which 6 out of 10 women (60%) or more of the mothers who have had C-sections go on to have their other babies through the birth canal.
3. Ask, “How do you allow for differences in culture and beliefs?”
Mother-friendly birth centers, hospitals, and home birth services are sensitive to the mother’s culture. They know that mothers and families have differing beliefs, values, and customs.
For example, you may have a custom that only women may be with you during labor and birth. Or perhaps your beliefs include a religious ritual to be done after birth. There are many other examples that may be very important to you. If the place and the people are mother-friendly, they will support you in doing what you want to do. Before labor starts tell your doctor or midwife special things you want.
4. Ask, “Can I walk and move around during labor?
What position do you suggest for birth?”
In mother-friendly settings, you can walk around and move about as you choose during labor. You can choose the positions that are most comfortable and work best for you during labor and birth. (There may be a medical reason for you to be in a certain position.) Mother-friendly settings almost never put a woman flat on her back with her legs up in stirrups for the birth.
5. Ask, “How do you make sure everything goes smoothly when my nurse, doctor, midwife, or agency need to work with each other?”
Ask, “Can my doctor or midwife come with me if I have to be moved to another place during labor? Can you help me find people or agencies in my community who can help me before and after the baby is born?”
Mother-friendly places and people will have a specific plan for keeping in touch with the other people who are caring for you. They will talk to others who give you birth care. They will help you find people or agencies in your community to help you. For example, they may put you in touch with someone who can help you with breastfeeding.
6. Ask, “What things do you normally do to a woman
in labor?”
Experts say some methods of care during labor and birth are better and healthier for mothers and babies. Medical research shows us which methods of care are better and healthier. Mother-friendly settings only use methods that have been proven to be best by scientific evidence.
Sometimes birth centers, hospitals, and home birth services use methods that are not proven to be best for the mother or the baby. For example, research has shown it’s usually not helpful to break the bag of waters.
Here is a list of things we recommend you ask about. They do not help and may hurt healthy mothers and babies. They are not proven to be best for the mother or baby and are not mother-friendly.
They should not keep track of the baby’s heart rate all the time with a machine (called an electronic fetal monitor). Instead it is best to have your nurse or midwife listen to the baby's heart from time to time.
They should not break your bag of waters early in labor.
They should not use an IV (a needle put into your vein to give you fluids).
They should not tell you that you can't eat or drink during labor.
They should not shave you.
They should not give you an enema.
A birth center, hospital, or home birth service that does these things for most of the mothers is not mother-friendly. Remember, these should not be used without a special medical reason.
7. Ask, “How do you help mothers stay as comfortable as they can be? Besides drugs, how do you help mothers relieve the pain of labor?”
The people who care for you should know how to help you cope with labor. They should know about ways of dealing with your pain that don’t use drugs. They should suggest such things as changing your position, relaxing in a warm bath, having a massage and using music. These are called comfort measures.
Comfort measures help you handle your labor more easily and help you feel more in control. The people who care for you will not try to persuade you to use a drug for pain unless you need it to take care of a special medical problem. All drugs affect the baby.
8. Ask, “What if my baby is born early or has special problems?”
Mother-friendly places and people will encourage mothers and families to touch, hold, breastfeed, and care for their babies as much as they can. They will encourage this even if your baby is born early or has a medical problem at birth. (However, there may be a special medical reason you shouldn't hold and care for your baby.)
9. Ask, “Do you circumcise baby boys?”
Medical research does not show a need to circumcise baby boys. It is painful and risky. Mother-friendly birth places discourage circumcision unless it is for religious reasons.
10. Ask, “How do you help mothers who want to breastfeed?”
The World Health Organization made this list of ways birth services support breastfeeding.
They tell all pregnant mothers why and how to breastfeed.
They help you start breastfeeding within
1 hour after your baby is born.
They show you how to breastfeed. And they show you how to keep your milk coming in even if you have to be away from your baby for work or other reasons.
Newborns should have only breast milk. (However, there may be a medical reason they cannot have it right away.)
They encourage you and the baby to stay together all day and all night. This is called “rooming-in.”
They encourage you to feed your baby whenever he or she wants to nurse, rather than at certain times.
They should not give pacifiers (“dummies” or “soothers”) to breastfed babies.
They encourage you to join a group of mothers who breastfeed. They tell you how to contact a group near you.
They have a written policy on breastfeeding. All the employees know about and use the ideas in the policy.
They teach employees the skills they need to carry out these steps.

Would you like to give this information (and more)
to your doctor, midwife, or nurse?
This information taken from The Mother-Friendly Childbirth Initiative written for health care providers. You can get a copy of the Initiative for your doctor, midwife, or nurse by mail, e-mail, or on the Internet.
To Get a Copy by Mail
Write to:

Coalition for Improving Maternity Services (CIMS)
1500 Sunday Drive Suite 102
Raleigh, NC 27607
Tel 1: 888-282-CIMS
Tel 2: 919-863-9482
Fax: 919-787-4916

Permission granted to freely reproduce in whole or in part along with complete attribution.
To Get Copies on the Internet

please vivist their site. they have lots of useful info on there.

i feel like this is a long post so i'll stop for now but i think i'll continue on with this topic tuesday....

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